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Oncology: An ounce of surgical planning worth a pound of long-term treatment

It is well known that the first attempt at surgery is the one most likely to provide control and/or "cure" of the tumor.

Surgeries that are not well planned may jeopardize the long-term prognosis of the patient. There are several axioms that have been used to define surgical oncology, including "measure twice, cut once," "go wide, go deep" and "the tip of the iceberg."

Surgical oncology is not always for the faint of heart. The temptation of doing a less-aggressive surgery due to concerns over reconstruction should be avoided. Pre-surgical planning is crucial to the success of surgery. The first consideration should be how to remove the tumor with a wide margin. Once that is determined, then the decision can be made regarding the best method for closure.

Reconstructive techniques such as grafts, flaps and implants are sometimes needed to close a wound. Tension-relieving techniques prior to surgery (skin stretchers) or following surgery (tension relieving sutures or buttons) can be used for locations that may have delayed healing due to tension on the incision. In some cases it may be appropriate to allow a wound to heal by second intention.

When excising a tumor, it is recommended that the tumor and surrounding normal tissue margins be removed en bloc. Incision into the tumor can lead to contamination of the surgical field, thus increasing the risk of recurrence and complicating any further therapy.

One of the most dangerous phrases used in surgical oncology is "it shelled right out." There may be a capsule surrounding the tumor that is actually a pseudocapsule comprised of compressed normal and tumor cells. When a tumor is shelled out, the pseudocapsule and tumor cells are left behind.

Care should be taken when placing drains as the entire drain tract can potentially be contaminated with tumor cells. If a drain has been placed, it should be located such that it can be easily re-excised or included in the radiation field. The same principle also holds true for a biopsy tract.

The rule of thumb has been to take a 3-5 cm margin of normal tissue when excising a malignant tumor. In reality, this is not always feasible. The required margin may depend on the tumor type, location and size. The deep margin often is the most difficult to obtain and, if it is not possible to obtain a wide, deep margin, then at least one intact fascial plane below the tumor should be included.

If it is suspected that radiation therapy will be required post-operatively, it may be helpful to speak with the radiation oncologist prior to surgery because there are surgical considerations that may affect the efficacy of radiation therapy. Orientation of the scar is important as radiation travels in a straight line. If the scar is oriented such that there is a significant curve (i.e., over the thorax or lumbar region), then radiation therapy planning becomes more difficult and treatment may be suboptimal.

Strategically placed hemoclips may facilitate more accurate identification of the tumor extent for radiation-therapy planning.

Although all radiation oncologists do not use pre-operative radiation therapy routinely, some cases may benefit from the option.

Biopsy submission

Further treatment recommendations are made based on the histopathology report. If the report is inaccurate or incomplete, then any further recommendations that are made are subject to error. Proper submission of the specimen cannot be overemphasized. Offering clients the option of not submitting a specimen for biopsy is dangerous. Charges for specimen submission should be part of the surgical package fee.